186, and depression in 157. All those with PTSD, 66% of those with anxiety, and 71% of those with depression had served in Vietnam. PTSD was associated with increased atrioventricular conduction defects (OR 2.81, 95% CI 1.03-7.66, p < 0.05) and MI (OR 4.44, 95% CI 1.20-16.43, p < 0.05) adjusted for numerous socioeconomic and health risk factors. Depression was associated with increased arrhythmia (OR 1.98, 95% CI 1.22-3.23, p < 0.01). Anxiety disorder was not associated with any ECG abnormalities. The study is limited by the small number of subjects in each psychiatric group.

In another analysis, Boscarino (1997) examined the medical records of 1399 Vietnam veterans from the CDC VES, of whom 332 had PTSD, 17 years after exposure. Circulatory diseases (defined by ICD-9 codes 401-459) were more common in those with lifetime PTSD than in those without PTSD (25% vs 12.9%, OR 1.62, 95% CI 1.14-2.30) after adjustment for general technical test results at Army induction, race, region of birth, type of enlistment, Vietnam volunteer status, Army marital status, current age, hypochondriasis, physical limitations, psychiatric limitations, postinduction alcohol and drug dependence, cigarette pack-years, education level, and current household income. The study rates as a secondary study because the ICD-9 codes include a very broad range of conditions, including hypertension and angina.

A meta-analysis of 11 studies reporting on the association between PTSD and cardiovascular end points (either physician-diagnosed or self-reported), which included the secondary studies discussed above (but not the Kubzansky study), found that there was more angina but not more MI in war veterans with PTSD than in those without it (Gander and von Kanel 2006).

Summary and Conclusions

Clinical manifestations of cardiovascular disease take many years to develop, particularly in relatively young people like soldiers at war, so the original source of stress, in this context combat exposure and other forms of deployment stress, will have ended many years before the stress response, such as high blood pressure or MI, becomes apparent. The committee found that self-reports of many cardiovascular symptoms, such as increased heart rate and chest pains, are increased in deployed veterans, particularly those from the Gulf War, compared with their nondeployed counterparts.

Some of the studies reported an increase in hypertension related to deployment, but they are almost all based on self-reports, and others found no effect of deployment. A small increase in the prevalence of hypertension in deployed Gulf War veterans cannot be excluded, but the data cited above are inconsistent, and, because most are based on self-reports, not much reliance can be placed on them. The deployed veterans, particularly those who had unexplained symptoms after the Gulf War, probably sought more medical care, and this alone might increase the likelihood of receiving a diagnosis of hypertension. There are consistent findings that deployment to a war zone, particularly the Gulf War, is associated with an increase in self-reports of many physical symptoms, including chest pain and increased heart rate, but these symptoms do not necessarily imply any structural heart disease.

The two primary studies, one on Gulf War veterans and the other on Vietnam veterans, that used physical examinations for hypertension were both negative. Of the six secondary studies for hypertension, two were negative and four were positive.

Blood lipids, another important risk factor for CHD, do not appear to be affected by deployment, although PTSD may raise them.

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